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Palliative Care Toolkit

Best-practice tools from around the world are provided here to support primary care providers with palliative care delivery.

3-Step Best Practice Model

The palliative care tools are organized according to the 3-step model of best practice proposed by the Gold Standards Framework used in the United Kingdom.

Step 1: Identify

Identify if the patient would benefit from palliative care early in their illness trajectory.

The following triggers help identify patients who may benefit from palliative care: 

  • The Surprise Question: “Would you be surprised if the patient were to die in the next year?”
  • Indicated preference or need for comfort care
  • General indicators and disease specific indicators

Specific details for Step 1 are described in the Early Identification & Prognostic Indicator Guide (PDF) developed by the Mississauga Halton Health Integration Network. This tool was adapted from the Gold Standards Framework Prognostic Indicator Guidance Tool.

Step 2: Assess

Assess the patient’s current and future needs and preferences across all domains of care. Assessment should include validated screening tools, an in-depth history, physical examination and relevant laboratory and imaging tests. Specific details on domains are described in Domains of Issues Associated with Illness and Bereavement (PDF).

Screening Tools

Screen regularly for distress and other needs using validated screening tools. Type and timeline of assessments depend on the severity, extent of life interference, urgency and complexity of the symptoms or needs identified.

Conversation and Consent Tools

Use the results of screening to prompt further discussions about a person’s wishes, values, beliefs, understanding of wellness and any illnesses, and goals for current and future care. These conversations are ongoing and should be revisited regularly.

Step 3: Plan and Manage

Plan and collaborate ongoing care to address needs identified during the assessment. This includes prompt management of symptoms and coordination with other care providers.

Cancer Care Ontario’s Collaborative Care Plans

Ontario Documents & Forms

The following documents and forms are Ontario-specific resources that may be required as part of the care provided.

Other Palliative Care Tools

These are additional palliative care tools created by Cancer Care Ontario and other organizations.